Delving into diuretics

diuretics Delving into

In his regular column for Emphasis, Consultant Pharmacist Neil Hamilton explains the role of ‘water tablets’ in managing PH.

After what has been a difficult time for everyone, I hope that we are all able to look forward to the new world of ‘living with’, rather than in fear of, COVID-19.

Most of the British public have now been vaccinated and optimistically, as I write, it seems as though case numbers are falling from the peak of the third wave. With schools and university students back, shops and restaurants bedding into the ‘new normal’ and crowd events such as football and music concerts restarting, life is steadily getting back to how it was before the pandemic. I hope that being fully vaccinated gives enough reassurance to the most clinically vulnerable, because time is precious, and we all need to get back to living life to the full.

The PH centres have continued to see patients, albeit in very different ways to before, throughout the pandemic. We had to prioritise our face-to-face appointments to those most in need. This recognised the limitations we faced in terms of distancing, stretched staffing resources and securing our patients from transmission. However, the PHA UK’s research also clearly described the huge anxiety amongst some of our patients about attending any appointments (or even leaving their homes for any reason) - however important they were. Telephone, and sometimes video, appointments were quickly brought in across all the PH centres for us to keep in touch with all our patients. This has undoubtedly been successful and will continue in the future to bridge the gap between less frequent clinic attendances.

Whilst the ‘non-face-to-face’ appointments have been a necessity, it is far more difficult to manage some of the consequences of PH such as fluid retention or heart failure this way. We have seen some very unfortunate cases where patients have been admitted to our unit in Sheffield with legs swollen up to (and even higher) than their thighs. Such patients have needed lengthy hospital stays for intravenous diuretics in order to offload the fluid. Whilst we can never say for certain, it is likely that if these patients had confidence to access their GPs, local services, or been able to come to a hospital appointment, these symptoms may have been dealt with far earlier.

If you have PH, you are advised to keep a close eye on signs of fluid retention, as this can be an indication of heart failure and worsening PH. Fluid retention, also sometimes called oedema, may be widespread around the body (especially in younger patients) but is most commonly seen around the feet and ankles. Whilst invisible from the outside, heart failure can cause fluid include furosemide and bumetanide (loop diuretics) bendroflumethaizide (a thiazide diuretic) and spironolactone, epleronone and amiloride (potassiumsparing diuretics).

Different types of diuretic may be combined if oedema persists with only one. For example, loop diuretics such as furosemide are often combined with potassium-sparing diuretics such as spironolactone. This ensures that potassium levels are kept at safe levels in the blood. Potassium is very important, not least to maintain a normal heart rhythm.

Anyone on diuretics will need regular blood tests to closely check kidney function and salt levels (including potassium). This is even more crucial if thiazide and loop diuretics are combined, or you are prescribed high doses of any of these medicines. This is because of the risk of putting strain on the kidneys in order to treat the heart failure. Doctors will prescribe the lowest effective dose that keeps the swelling down, in order to try and avoid these complications if possible.

Whilst essential for many of you with PH, diuretics are not without side effects, usually as a result of the salt level disturbances. On starting someone on diuretics, we will discuss increased thirst, headache, low blood pressure, fatigue and gastrointestinal symptoms. Unfortunately, some diuretics can cause increased sensitivity to sunlight, so extra care is needed on sunny days. We will also make it clear that diuretics will make you go to the toilet more than normal (which is necessary to lose the excess fluid). In order not to ‘undo’ the effectiveness, we also discuss the need for drinking a sensible amount of fluid each day. It is also sensible to watch

“You should keep a close eye on your own fluid status at home”

to build up around the lungs, causing shortness of breath.

In order to keep their oedema to a minimum, many, but not all, people with PH are prescribed diuretics, or ‘water tablets’. Diuretics work by causing the kidneys to increase the amount of salt and sodium that is filtered out of the blood and into the urine. When these salts are filtered out of the blood by the kidneys, water is also drawn alongside (like a magnet). By removing the excess fluid, they make it easier for the heart to pump blood around the body. This is useful in heart failure where the pumping mechanism of the heart is less effective

Diuretics commonly used in PAH for sudden changes in weight, as this might indicate worsening heart failure.

As diuretics make you produce more urine, for very practical reasons it is recommended that these are taken in the morning (for once-daily dosing) with a second dose at lunchtime if prescribed. In exceptional circumstances, it is possible to make minor adjustments to the time at which you take your diuretics. They can be taken later in the day, to make it easier to deal with car journeys or important appointments. If you miss your dose prior to an appointment with a doctor or nurse, you must tell them of this change, or otherwise they may think that the diuretic is not working properly.

In summary, diuretics are fairly commonly prescribed in PH, but doses are kept to a minimum in order to avoid side effects and putting strain on the kidneys. You should keep a close eye on your own fluid status at home, which can be done by periodically weighing yourself on bathroom scales. If lots of fluid is allowed to build up unchecked, it can result in the need for higher doses, frequent blood tests and even hospitalisation. As always, your local pharmacist or the team at the specialist centre will be happy to give advice regarding diuretics, dosing, blood tests and how side effects can be managed. .

FACT: Fluid retention can also be referred to as oedema

theinterview

“Every day this role gives me the opportunity to meet truly inspirational people all around the UK”

CLINICAL NURSE SPECIALIST JAVIER JIMENEZ

in conversation with Mary Ferguson

Javier Jimenez trained as a nurse in Spain and swapped sunshine for the city when he moved to join our NHS. Now a Clinical Nurse Specialist at the Royal Free Hospital in London, Javier reflects on his path to PH and the rewards and opportunities of his role.

Q. What initially attracted you to nursing?

A: What led me into nursing was my passion to do right by others and make sure I do whatever I can to help someone. It’s a rewarding feeling knowing you are able to make someone’s life better and a litter easier. Even when I was young I was fascinated by going to the doctor in my town. I would come home and play hospital and do my own clinical consultations with my family. I studied at the University of Girona and I had many roles before I came to the UK, especially in my training to become a nurse. I worked as a Nursing Assistant and as a nurse in a nursing home. I also worked in an emergency department and in the ambulance service in Girona.

Q. What made you decide to come to the UK?

A: I’m from a small town called Palafrugell, in the Costa Brava, but in my heart I have always been a city boy. I came to London many times before I made the move here and fell quickly in love with its charm and its history. I had a good understanding of English but I wanted to improve my linguistic skills - and I knew there was such opportunity within the NHS for personal growth and development. These were the main factors that drew me to UK.

Q. And what led you to the field of PH?

A: When I finally made the move to the UK, I started to work in a stroke unit at Northwick Park Hospital as a nursing assistant - a short-term role while I waited to receive my Nursing and Midwifery Council pin number. Once I had settled, I worked as a full nurse in the same unit for a couple of years. During this time, I gained real understanding about nursing in the UK and I was able to build my confidence with my English and make new friends in the city. I finally applied for a job in the Royal Free Hospital, where I started to work in an interventional radiology and cardiology unit. Whilst here I started to hear...

“I work with the best people; we all share the same goal and path”

...about pulmonary hypertension, and I was able to move o my current post. I always wanted to challenge myself, and I knew this would be a specialised role presenting a great opportunity to be able to learn, develop and grow. I’m someone who likes to continue learning, developing and progressing in my career.

Q. What are the rewards and challenges of your job?

A: I think I enjoy the teaching side the most. I love to teach and train others - including patients, relatives and other healthcare workers. I also love to feel useful to the patients; to feel that I can help them with their therapy, symptoms and any other issues or queries that they might have. We go into the roles of caring for others because we want to make positive change to people’s lives, but it can always be challenging when at times we don’t always see the outcome we hope for. But every day this role gives me the opportunity to meet and interact with some truly inspirational and caring people all around the UK, and this is such a rewarding and humbling experience. Plus, I work with the best people; we all share the same goal and path.

Q. What has it been like working as a nurse through the COVID-19 pandemic?

A: COVID-19 has been a challenge which we all have shared within the NHS. It’s taken its toll on us as people and also on our patients. I was redeployed during the first wave to a COVID-19 ward. I was able to help the ward staff with the extra workload and help our patients get the care they needed. However, like a lot of services throughout the NHS, COVID-19 has had a knock-on effect and caused a patient waiting list to grow. Q. How does PH care in the UK compare to PH care in Spain?

A: Spain doesn’t have Clinical Nurse Specialists as we know them here in the UK. That role is mainly carried out by doctors. The specialist nurses in Spain are more for big groups, like geriatric, pediatric, and midwifery, but not for specialties like PH. This is one of the things that attracted me to come to the UK and work for the NHS.

Q. What excites you most about the future of PH care?

A: The new ways used to manage and care for our patients. I think the pandemic has accelerated this. The nursing team has always done remote clinics by phone - especially with those starting new therapies, and particularly IV epoprostenol. But now we can do these clinics with video. This is a big improvement as we can see the patients, assess their skin tunneled line, and do part of the training too. I think this is a big step forward, as is easier to review the patients if you can see them.

Q. What do you enjoy about living in England?

A: I definitely don’t enjoy the weather! I love its history. Visiting historical places and learning UK history it’s something I enjoy a lot. I also love the multiculturalism in London and other big cities in the UK.

Q. And what do you miss about Spain?

A: I miss the weather, food, and of course my family and friends. I used to be able to visit Spain quite often [before the pandemic]. I also miss going to the Pyrenees to practice snowboarding. I haven’t been there for a very long time, but hopefully I can visit my family and friends soon.

Q. Finally, how do you relax away from work?

A: I love sports, travelling and cinema. I try to swim every day after work, and I love snowboarding during Spanish winters. My family lives an hour away from the Pyrenees, so it’s not difficult to get to a ski resort when I’m visiting them.

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